episiotomy question

[tearose]

Are there cases where it's beneficial to have an episiotomy? Before having my first child (fall 09), I had read that natural tearing healed faster and that few obs do routine episiotomies--so this never came up in my check-ups. I had an extremely fast birth, and I was surprised when the ob (he was on call then but is now my primary ob for this pregnancy) brought it up. He told me the pros, but DS decided that he couldn't wait, and he was born before the ob could tell me the cons. Perhaps because things happened so quickly, I did have a fair amount of tearing, but I ended up healing okay.

 

I like my doctor a lot, and I feel like he's respectful of my decisions. I can bring it up with him, but I'd also like to be better informed in case a different doctor is on call. For context, I am not committed to doing things naturallly. I planned on getting an epidural with my first child but didn't because things happened so quickly. I'd like to have one this time around but am okay with that not working out again. I really like my ob and hospital and trust both to respect my choice. What would be my best choice in terms of pain and recovery if the issue comes up? Thanks, ladies!

[Emerkaza]

Please keep in mind, I am speaking from personal experience. I have had four children. I had episiotomies with the first two (I wasn't offered the choice and didn't know any better). It was very painful afterwards and took quite a while to heal. With my 3rd and 4th babies, I told the doctors that I did not want an episiotomy. My dh and I did the perineum stretching exercises during my third trimester. The kids were both 7+ pounds and I had little to no tearing. No sutures required. The healing process was so much easier and faster. It was a huge difference for me. :-)

[Starr]

You can read differing opinions on this one. :)

[DarlaS]

Please keep in mind, I am speaking from personal experience. I have had four children. I had episiotomies with the first two (I wasn't offered the choice and didn't know any better). It was very painful afterwards and took quite a while to heal. With my 3rd and 4th babies, I told the doctors that I did not want an episiotomy. My dh and I did the perineum stretching exercises during my third trimester. The kids were both 7+ pounds and I had little to no tearing. No sutures required. The healing process was so much easier and faster. It was a huge difference for me. :-)

 

:iagree:

 

Very similar experience here. My 3rd & 4th babies were born at home and both 9lbs. I had a little tear with #3, none at all with #4. (I was also on my side for both births.)

[Caitilin]

The thing is, you might NOT tear. If you have an episotomy, for sure you're going to have to heal from that. I have a midwife who'd never done one, as a matter of principle, so it was a non-issue for me, but I would have refused one regardless. As it happened, I tore a bit with my first VBAC, but not at all with the other two, both of which were larger babies. I would never willingly submit to one except to literally save baby's life. As usual, YMMV.:001_smile:

[Impish]

I've had 4 children. When expecting my first, my best friend's mom warned me about episitomies, and told me that the best thing to do was sit directly on the stitches, that the pressure helped ease the pain.

 

He ended up being a csection, and the first thing she said to me when she came to see us was, "Don't sit on these stitches!" :lol:

 

Diva, I had an epis. She was a forcept delivery. I requested, and received one directed towards my thigh, rather than straight down. Apparently more painful, but I was worried about further tearing.

 

I remember the Dr stitching me up, and asking him if he was making a quilt. He quipped, "No, putting in my initials!" He was awesome.

 

Two since then, no epis. The OBs I had did massage and stretching. I've had minor tears, no stitches required.

[Susan C.]

It was better having one for me..... both kids had 14" heads and I am small.... first had one, second didn't because she came too fast, and I tore forward and had stitches there, and it was not pleasant!

[KidsHappen]

I had shoulder distocia with one of my 10 1/2 pounders and got a thrid degree tear. I healed fine with no problems. While I see absolutely no need for a routine one and I would have preferred possibly tearing to definitely getting cut, I would have accepted one if it had been the safest way to get the baby born. This article list some legit reasons why it might be considered: http://en.wikipedia.org/wiki/Episiotomy

 

ETA: I subsequently had another 10 1/2 pounder with no epi and no tearing. I believe the previous one was soley due to the shoulder distocia.

Edited May 2, 2011 by KidsHappen

[Carrie12345]

For the most part, episiotomies are only useful for making room for tools (forceps, vacuum, etc.)

 

I've never actually had one. I have had deliveries with no tearing, deliveries with minor tearing, and one delivery with major tearing (fetal distress, and I was determined to get him out before they could get the OR set up).

 

In my experience, the difference came down to controlled pushing (or uncontrolled pushing, depending on the case!)

My kids ranged from 7lb9oz to 9lb2oz, most with 14" heads. My experiences don't correlate with their sizes, but they do correlate with how controlled my pushes were.

 

I never did any perenium "exercises" in preparation.

[tearose]

I didn't think to mention that I am petite--about 5 feet tall, 105-110 lbs (I weigh a somewhat more now that I'm pregnant, of course, but that gives you an idea of my frame). Would that have much of an impact on whether or not I'm likely to tear?

[PeterPan]

Well I've birthed a 9lb. 4 oz. and an 11lb. 1 oz. and didn't tear with either of them. The smaller of those two was on land with perineal massage. The 2nd was in water. No tearing with either. Same midwife with both. Since this is a 2nd baby, you're more likely to stretch. The water helps stretch things too. Like I said, 11 lb baby and NO tears, none at all. Find the practitioner to help you have the birth you want.

[Carrie12345]

I didn't think to mention that I am petite--about 5 feet tall, 105-110 lbs (I weigh a somewhat more now that I'm pregnant, of course, but that gives you an idea of my frame). Would that have much of an impact on whether or not I'm likely to tear?

 

I'm unaware of any correlation between height and/or weight and vaginal elasticity. ;)

[Hannah C.]

You can find all sorts of info about this online. Basically, an episiotomy is supposed to be better than tearing naturally. However, once you get the episiotomy you can tear more, and if you don't have the episiotomy it is possible that you won't tear at all. If doctors need to use vacuum/forceps to get the baby out, or something along those lines, I could see why an episiotomy would be medically necessary.

 

From what I've read, the likelihood of tearing doesn't actually have much to do with baby's size - it's more how the pushing happens. So if you're pushing and pushing and baby comes out faster, tearing is more likely to happen regardless of the baby's size.

 

Personally, I would rather tear instead of be cut [based on my own personal squick factor]. I had my baby with a midwife who doesn't do episiotomies. I did end up tearing, but it wasn't nearly as bad as I thought it would be.

[ktgrok]

There is NO evidence that episiotomies are beneficial in most cases. In fact they go through more layers of muscle and predispose you to tear even further. I had a 3rd degree tear with my 9lb vbac, but it was my fault. I refused to slow down my pushing as I just wanted it over with. sI'm still glad it wasn't an episiotomy. I watched a doctor cut one on my girlfriend and it was awful. Scissors do not belong there!

[texasmama]

I don't think your height/weight makes a great deal of difference regarding this issue. If you can get the baby past your hips, the rest of the equipment is roughly the same size as the general population's.:tongue_smilie:

 

I had three episiotomy births and one without. The one without was MUCH easier to heal from and much less painful. I had some tearing and some stitches, but it was truly a night and day difference. Also, I had two natural childbirths, one with an episiotomy and one without. Couldn't feel the tear or the cut either time, just the pain of baby being born. Those babies were both 8 1/2 pounds.

Edited May 2, 2011 by texasmama

[BigMamaBird]

I have had episiotomies with both my deliveries. I didn't experience any additional pain that I would blame on the episiotomy, just the recovery of childbirth.

 

A girlfriend of mine did not opt to have one and tore all the way to her @nus she was in a great deal of pain and seemed to take a long time to heal. Because of that I discussed an epi. beforehand with my dr. He gave me the choice during delivery to have one or to tear, I chose to have one.

 

I was given a little squirt bottle and told to rinse off with warm water each time I used the toilet. Like I said, there was never any remarkable pain that I could pinpoint on the epi.

[Pretty in Pink]

I'm 5'3", weigh 100 lbs, and I've given birth four times. I had an episiotomy with the first because the doctor delivering was an intern and it was his first delivery. The supervising OB thought that he needed the practice. I didn't have one with my other three deliveries and I didn't tear at all with any of them.

 

I am sure that episiotomies are sometimes useful for delivering exceptionally large babies or when the accommodation of surgical instruments within the birth canal is necessary to facilitate delivery, but you can't predict in advance whether you'll require one or not based on the fact that you are petite.

 

In terms of discomfort during recovery, my first birth was much more painful to recover from. Holy cow was it painful.

Edited May 2, 2011 by Pretty in Pink

[Carol in Cal.]

I told the OB that I would rather have a C section than an epi. She put 'patient refuses episiotomy' into my orders. The labor nurse asked me about that. By then I had read up on it. I told her that if the baby was coming out in such a way so that things were likely to tear forward, to go ahead and prevent that. Didn't happen, no epi, no problem. Tore a little, used the squirt bottle too, was on a plane across the country 2 weeks post-partum--that's how fast I was healing.

 

I have a friend who tore a lot right at the end--she is not sure why, but she developed BOWEL incontinence which didn't resolve for several months. That's all I know--I don't know why, I don't know whether an epi would have prevented this. I had never even heard that this was possible in modern medical environments, so it's maybe worth looking into.

[Veritaserum]

Episiotomy may beneficial if:

1. Baby is in trouble and minutes/seconds matter.

2. It looks like a tear is going to up to more sensitive areas. A position change on the mother's part could redirect the pressure as an alternative to episiotomy.

3. Forceps are needed. Some docs will do forceps without cutting an episiotomy.

 

Episiotomy comes with risks (compared to natural tears/no tearing):

1. Increased pain during healing.

2. Increased time for recovery.

3. Likelihood of more extensive damage, including tears clear through the rectum. Reconstructive surgery may be needed.

4. Increased risk of infection.

5. Increased chance of pain during intercourse.

 

Ways to reduce the risk of tearing:

1. Push in any position OTHER than on your back or semi-reclined/sitting. Although these two positions are the most common for American hospital births, they increase the likelihood of tearing AND can increase total pushing time. Side-lying is a much better choice and can be used even if you have an epidural.

2. Perineal support during pushing. If your doctor places a warm, wet cloth on the perineum and provides counterpressure as the baby's head is emerging, tearing is less likely. The baby's head gets redirected through the existing opening. ;)

3. Take it slow. More time for the tissues to open and unfold means less damage or even no damage to those tissues. :)

 

ETA: I tore with my first baby (semi-sitting, epidural). I tore less (4 stitches) with my second baby (waterbirth, compound presentation with her hand by her head). I didn't tear at all with my others (kneeling in the water with perineal support). :)

Edited May 2, 2011 by Veritaserum

[SonshineLearner]

My suggestion would be to have the midwife literally stretch you "apart" both horizontally and vertically with her whole hands... This hurts, but not like tearing and healing. Then, stand for the birth. I went from tearing horribly with my 1st big baby, to not tearing at all with my 2nd... 10lb 3 ounce baby... No tearing! Yay!! A bit of bruising for a few days... SO much easier :)

[twoforjoy]

I had an episiotomy with both of my deliveries. With the first one, I pushed for 4 hours. By the end, I would have done anything to get the baby out, and the OB who was at the delivery told me that I could have the baby out in one more push with an episiotomy and maybe ten more if I didn't. (I have no idea how/if she actually knew that, and she was not the nicest doctor I've ever encountered.) I did not hesitate to ask for the episitomy. Looking back I don't know if that was the best choice, but after four hours of pushing, you're willing to do just about anything.

 

But, the recovery that time was rough. I was in a lot of pain for a while, and intercourse was painful for almost a year.

 

With my second, she came out FAST and had a big head. My OB (this time somebody I really trusted and knew--she was the same OB who did my prenatal care) thought that it was likely I was going to tear and said if I wanted she could do an episiotomy along the same cut as last time. We went with that option, and it went very well. The annoying part was that it seemed to take forever to get sewn up after, but they must have done a good job, because the recovery went really smoothly. I really don't remember having much if any itching, much less pain. Of course, DD broke my tailbone on her way out, so it's possible that I was in so much pain from that that I just didn't notice any other pain.

[DarlaS]

 

Ways to reduce the risk of tearing:

1. Push in any position OTHER than on your back or semi-reclined/sitting. Although these two positions are the most common for American hospital births, they increase the likelihood of tearing AND can increase total pushing time.

 

 

:iagree::iagree::iagree:

 

The above is hands down the biggest cause of both unnecessary epis and excessive tearing. I would even dare say a fair number of failure to progress and fetal distress leading to c-sections also. We are told to stay OFF our backs during pregnancy and they put us on our back the minute we go into labor? Crazy much? :001_huh:

 

It doesn't have to be either epi or tear. OB's who say that may truly believe it, but they really don't know much about normal birth (as opposed to typical).

[happyhomemaker25]

I did not have one and still ended up with a third degree tear because when she came after two hours of pushing she came quick!! LOL The Dr was not ready and they would not let me push for a full 2 minutes when she crowned. The tear was pretty bad, but it healed quicker than my friend who had the episi.

I will say that I did not know the Dr was going to do the massage thing in at the start of one of my contractions. It was the only time I SCREAMED during the whole labor and delivery. LOL The whole room stopped because I'd been so quiet up to that point.

[tearose]

All this info is really helpful, ladies. I had looked at some internet sites, but I'm never sure if they're pushing an all-natural just to be natural agenda or if there's a good reason in some cases. I was leaning a bit against having one, and I am happy to hear that tearing does not necessarily always happen. With my first, I don't think that I would have had time to stretch or massage because there was no stopping DS, and I didn't push at all. I guess I'm worried about the tearing because he was small (under 6 lb), and I still tore quite a bit. I may look into massaging the area in the weeks before labor, though.

[HS Mom in NC]

Do you mean the choices are have an episiotomy or tear? I would not use a birth attendant that thought those were the only two options. I would not consider birthing with an attendant that considers an episiotomy or tearing routine. My midwife has a less than 1% episiotomy rate and a less than 2% tear rate. This includes petite women delivering 10-12 lb. first babies and women delivering babies with shoulder dystocia (sp?) It's not either or. Find someone who routinely has clients with bodies in tact after a delivery.

 

My first child was less than 10 minutes of pushing. No tear. No episiotomy. Please don't listen to the staff screaming "Push! Push! Push!" at you. If you don't push as the baby crowns you'll stretch slower reducing your chances of tearing. If you're not on your back you'll do better. Find someone with experience in keeping women's bodies whole.

[wapiti]

IME, tearing heals much better/easier/quicker than an episiotomy (I had two of each - episiotomy tore worse).

 

I think whether to do an episiotomy or not may be a generational thing amongst the docs. My own mother was shocked and angry every time I didn't have one, LOL. "You mean they let you tear??" Um, mom, you're behind the times... The funniest one was my unmedicated birth - "ring of fire" indeed (seriously, afterward I couldn't get Johnny Cash in my head). I so did not care about tearing, and the freight train didn't either.

 

Once I had an episiotomy for an emergency situation, baby had to be out immediately. There was no discussion. Snip, push, out.

 

The one benefit I got out of the Hypnobirthing book was the "breathing the baby out" technique of not constricting your bottom while you're pushing. It was NOT the usual pushing technique like you're going to the bathroom. In the births for which I used that technique, I still tore, but I think it was a much more effective way to push, generally.

[Stages]

Warning: this is WAAAAY TMI:

 

Background: 38.5 weeks, 21 year old mother. Maximum pitocin drip and an epidural. The epidural stopped working on the right side of my body about three hours before she was born.

 

My first child was almost 8 pounds, born after 19 hours of labor and about 30 minutes of pushing. DD's head was stuck in my pelvis, so the first 20 minutes of pushing were entirely non helpful. It was literally "I see her hair!" and one push later a huge gush of blood and her entire head was out.

 

I had a 3rd degree tear- the doctor actually lost count of how many stitches I had. Many of my stitches tore since it was such a trainwreck, so even now, things aren't really the same around there.

 

Granted, I'm fairly certain I pushed when the nurse told me not to, but after that long and that much pain, I wasn't really listening to her. I wanted the **** baby out (in a loving way, of course!)

 

My tear was very jagged and took about 3 months before I could sit down without worrying about the tear (the hemorrhoids from the stitches took about 9 months after that to heal).

 

I would have gotten an episiotomy given the option, simply because the scaring would be more uniform. I don't think anyone realized how intense the tearing would be.

[dirty ethel rackham]

 

I have a friend who tore a lot right at the end--she is not sure why, but she developed BOWEL incontinence which didn't resolve for several months. That's all I know--I don't know why, I don't know whether an epi would have prevented this. I had never even heard that this was possible in modern medical environments, so it's maybe worth looking into.

 

Ummm. No. An episiotomy would NOT have prevented this. In all likelihood, it would have made things worse. One of the biggest predictors of rectal tears is an episiotomy (actually - a bigger predictor is a vacuum extraction with an episiotomy.) These injuries are rarely seen without an episiotomy.

 

The good news for your friend is that it did resolve after a few months. If she had torn into the anal muscle, she might still be experiencing fecal incontinence today because a sphincteroplasty has a terrible success rate (long term studies show only 50% have successful results.)

 

And about how to prevent getting an episiotomy or tearing ... find someone who rarely does them. Rarely means under 15%. If an OB thinks they are necessary more often than that, then he doesn't know how to handle a birth to minimize pelvic floor damage. Also, when the time comes, no matter how many times you have discussed the issue, if the doc wants to do one, he will do one and you can't very well stop him.

[kimnc]

I had an episiotomy with ds #1, and the recovery was very painful, much more so than with ds#2 where I had just a little tearing. Actually the only tearing I had with #2 was scar tissue from the episiotomy.

 

If you are not sure that the doctor will respect your wishes, I would hire a doula.

[Joker]

I hate episiotomies! I had one with dd1 and then ended up with a horrible tear through muscles that took months to heal. It took the drs. over an hour to stitch me up so family could see the baby. I ended up back in the hospital a few days after the birth because my body just didn't function normally and I couldn't "make" it work. Dd 2 was a very different story and I felt pretty normal within hours instead of months.

[newday]

The thing is, you might NOT tear. If you have an episotomy, for sure you're going to have to heal from that. I have a midwife who'd never done one, as a matter of principle, so it was a non-issue for me, but I would have refused one regardless. As it happened, I tore a bit with my first VBAC, but not at all with the other two, both of which were larger babies. I would never willingly submit to one except to literally save baby's life. As usual, YMMV.:001_smile:

Indeed!

 

There are lots of reasons that tears happen and they can happen even in the most ideal situations, but usually they are on the heals of directed pushing and/or back laying position. But naturally, the perinial tissue is made to stretch, and it should.

I do not recommend that anyone have a guaranteed wound over a possible wound.

 

There is NO evidence that episiotomies are beneficial in most cases. In fact they go through more layers of muscle and predispose you to tear even further. I had a 3rd degree tear with my 9lb vbac, but it was my fault. I refused to slow down my pushing as I just wanted it over with. sI'm still glad it wasn't an episiotomy. I watched a doctor cut one on my girlfriend and it was awful. Scissors do not belong there!

 

Exactly. Kind of like making the cut into a bit of fabric to enable yourself to give it a big rip...

 

 

 

If you are looking to minimize trauma to you perineal area then you should push only when you feel the urge, not sustained/directed pushing, and choose a position(s) for birthing which are well suited to birthing, which would be almost anything other than on your back.

[newday]

Do you mean the choices are have an episiotomy or tear? I would not use a birth attendant that thought those were the only two options. I would not consider birthing with an attendant that considers an episiotomy or tearing routine. My midwife has a less than 1% episiotomy rate and a less than 2% tear rate. This includes petite women delivering 10-12 lb. first babies and women delivering babies with shoulder dystocia (sp?) It's not either or. Find someone who routinely has clients with bodies in tact after a delivery.

 

My first child was less than 10 minutes of pushing. No tear. No episiotomy. Please don't listen to the staff screaming "Push! Push! Push!" at you. If you don't push as the baby crowns you'll stretch slower reducing your chances of tearing. If you're not on your back you'll do better. Find someone with experience in keeping women's bodies whole.

 

Very well said.

[I.Dup.]

I had an episiotomy with #1 (oh man was that horrid to recover from!!!!!!!) and I've had minor tears with 2 others, but no major tears. No episiotomies since my first.

 

The only birth I've witnessed, the mother had a very thick perineum. I'm not sure if it's normal, but it was a good 1.5" of girth covering the baby's head, all the way around. The Dr. called it a 'perineal body' and it was pretty surprising to see, actually. She ended up getting an episiotomy but I just don't see how the baby could have come through that otherwise. She said the recovery wasn't difficult for her at all.

[happypamama]

Another vote to say that you might not tear, or you might just tear a tiny bit. I've had three babies, all large, all with large heads, none in water, and I've never torn. A tiny skid mark with the third, only because I really wanted his head out and wasn't pushing gently (my choice, nobody coaching me to do that), plus his birth was very fast. (I'm also petite, but that really has nothing to do with it. I've heard that fair-skinned women tend to tear, but not in my case. I've also heard that if you get stretch marks, you're more likely to tear, but again, not in my case.)

 

I agree with the previous posters who said that a care provider shouldn't offer just episiotomy vs. tearing. My midwives have provided support to the perineum, and in some cases, we've used warm compresses to soften the tissues. I've heard of olive oil being used for that too. But I think some of it is just the luck of the draw, and a large part of it is pushing with your own urges and not someone else's direction, as well as getting in a good position (side-lying is great). Good reasons to skip the epidural, so that you can be more in control of yourself.

[Joker]

If you are looking to minimize trauma to you perineal area then you should push only when you feel the urge, not sustained/directed pushing, and choose a position(s) for birthing which are well suited to birthing, which would be almost anything other than on your back.

 

 

I think this is important. I had a normal labor with dd1. I was in labor for 13 hours and only pushed when the drs told me to push. They gave me an epis. and then I tore horribly on top of that.

 

I was only in labor with dd2 for an hour and a half. It was quick and I could do nothing but listen to my body. It pushed whether I wanted it to or not and the recovery was 100x better than what I went through with first dd.

[newday]

I had an episiotomy with #1 (oh man was that horrid to recover from!!!!!!!) and I've had minor tears with 2 others, but no major tears. No episiotomies since my first.

 

The only birth I've witnessed, the mother had a very thick perineum. I'm not sure if it's normal, but it was a good 1.5" of girth covering the baby's head, all the way around. The Dr. called it a 'perineal body' and it was pretty surprising to see, actually. She ended up getting an episiotomy but I just don't see how the baby could have come through that otherwise. She said the recovery wasn't difficult for her at all.

 

The babies very rarely get stuck on the perineum. I have talked with quite a few midwives about this and once in 100 (rough guess) they will run into a mama with seemingly metal tissue in that area, sometimes in those situations they will choose to cut. :(

But generally if there is a thickness to the perenial tissue then it hasn't sufficiently stretched out...

[dirty ethel rackham]

One thing I forgot to mention ...

 

Perineal lacerations are graded 1 - 4.

 

1st degree lacerations involve skin only. When left alone, IF the perineum tears, it is usually a 1st degree. Small ones are often called "skid marks" and may not even need stitching.

 

2nd degree lacerations involve skin and muscle. By definition, an episiotomy is a 2nd degree laceration. These do require repair. While a tear may be jagged, it may heal better because there is more surface area to knit together. A clean cut does not necessarily heal better or stronger.

 

3rd degree lacerations involve tearing into the anal sphincter muscle. These require a more extensive repair, which isn't always successful. 3rd degree lacerations are RARELY seen without an episiotomy.

 

4th degree lacerations tear into the rectum. Again, these are rarely seen without an episiotomy. Also, these do require more extensive repair. Since it involves the anal sphincter, there may be long term problems just like with a 3rd degree.

 

An important question to ask your healthcare provider is what they do to help you birth without tearing. How often do they need to stitch up their patients? If they have to do it all the time, they do not know how to preserve the perineum. Oh, and it isn't just about whether or not the perineum tears. It also has to do with preserving pelvic health in the long run. There is a lot of connective tissue that keeps the pelvic organs in place. Rushing the birth, directed pushing, physiologically improper pushing positions can all impact future pelvic floor health. I am dealing with prolapses due to an unnecessary vacuum extraction with my first child that resulted in a 3rd decree laceration that never healed properly, despite 2 repair surgeries. I am passionate about this subject.

[fairfarmhand]

I just want to chime in to say that tearing/epi is not universal.

 

I've birthed 4 babies...not a single stitch... Only had a teeny little tear on baby number 3.

 

My first 2 were epidurals, last 2 were natural.

[Janie Grace]

Another voice in favor of NO epis. and making sure your provider knows how to minimize tearing. My midwives have used:

- Vit. E oil

- Warm compresses

- Counter pressure

AND, most importantly, making sure I did NOT push while crowning. The most helpful advice I was given was to make short little grunts while crowning. Focusing on doing something that doesn't LET you do one big push is more helpful than just being told "don't push."

 

If your provider isn't versed in these methods, I'd educate him/her or find a new one.

[happyhomemaker25]

One thing I forgot to mention ...

 

Perineal lacerations are graded 1 - 4.

 

1st degree lacerations involve skin only. When left alone, IF the perineum tears, it is usually a 1st degree. Small ones are often called "skid marks" and may not even need stitching.

 

2nd degree lacerations involve skin and muscle. By definition, an episiotomy is a 2nd degree laceration. These do require repair. While a tear may be jagged, it may heal better because there is more surface area to knit together. A clean cut does not necessarily heal better or stronger.

 

3rd degree lacerations involve tearing into the anal sphincter muscle. These require a more extensive repair, which isn't always successful. 3rd degree lacerations are RARELY seen without an episiotomy.

 

4th degree lacerations tear into the rectum. Again, these are rarely seen without an episiotomy. Also, these do require more extensive repair. Since it involves the anal sphincter, there may be long term problems just like with a 3rd degree.

 

An important question to ask your healthcare provider is what they do to help you birth without tearing. How often do they need to stitch up their patients? If they have to do it all the time, they do not know how to preserve the perineum. Oh, and it isn't just about whether or not the perineum tears. It also has to do with preserving pelvic health in the long run. There is a lot of connective tissue that keeps the pelvic organs in place. Rushing the birth, directed pushing, physiologically improper pushing positions can all impact future pelvic floor health. I am dealing with prolapses due to an unnecessary vacuum extraction with my first child that resulted in a 3rd decree laceration that never healed properly, despite 2 repair surgeries. I am passionate about this subject.

 

Huh, my OB said mine was 3rd degree because of how deep it went. It was nowhere near my anal spinchter and was a tear. It took some stitches. It healed nicely. My friend had a 3rd degree tear at a different hospital different OB who said the same thing.

I really don't know. Just what we were told.

[dirty ethel rackham]

Huh, my OB said mine was 3rd degree because of how deep it went. It was nowhere near my anal spinchter and was a tear. It took some stitches. It healed nicely. My friend had a 3rd degree tear at a different hospital different OB who said the same thing.

I really don't know. Just what we were told.

 

What I posted is what I had found in medical dictionaries when I was studying to be a childbirth educator. Also, most medical studies about epsiotomies and perineal tears classify the lacerations they way I had posted. It sounds like those doctors were using the terminology differently than what is in the scientific literature.

[tearose]

I guess my question is more along the lines of what would be best if one doesn't have time for stretching, massage, applying oil, etc.? Obviously, I could have a completely different birth experience from my first, but what are the best options if labor is really fast? I was advised to slow down / stop pushing, but trying to stop DS was like trying to stop a freight train--totally beyond my control.

[Janie Grace]

I guess my question is more along the lines of what would be best if one doesn't have time for stretching, massage, applying oil, etc.? Obviously, I could have a completely different birth experience from my first, but what are the best options if labor is really fast? I was advised to slow down / stop pushing, but trying to stop DS was like trying to stop a freight train--totally beyond my control.

 

My births are really fast, too (like between 3 hours and 30 minutes). Warm compresses and oil can be applied very quickly (esp. if the doc/midwife is clued in to your labor patterns), and even if the baby is coming fast, you can ease up on the urge to push by doing short breaths or grunts as he is crowning/coming out.

 

By the way, don't expect it to be as fast or faster, necessarily. My 2nd was faster than my 1st but 3rd was longer than both. Who knows!

[Spy Car]

I'm going to get in (and out) of this thread without reading other responses, but in my very limited experience with these things, I have witnessed how an obstetrician can deliver a child humanely without the need for either tearing or episiotomies. My wife's doctor took moments during the delivery to gently pull back and manipulate tissues so they would not tear. The doctor told me that he had never cut a woman during his practice and that my wife would not be the first. And he used his skills to prevent her from tearing.

 

There is a humane way to deliver children. I will be eternally grateful we had a physician who practices such methods and wish that was the standard of care all women would receive.

 

Bill (bowing out)

[LizzyBee]

I asked my doctor about the statistics, and she said that in her clinical experiences, episistomies heal faster and better than tears. I had a small episiotomy with my first, but I think I tore with the 2nd one because she came so fast (1 push). I don't remember any significant pain or discomfort afterward with either of them. Third one was a C-section, so no episitomy or tearing with her.

Edited May 2, 2011 by LizzyBee

[Veritaserum]

I guess my question is more along the lines of what would be best if one doesn't have time for stretching, massage, applying oil, etc.? Obviously, I could have a completely different birth experience from my first, but what are the best options if labor is really fast? I was advised to slow down / stop pushing, but trying to stop DS was like trying to stop a freight train--totally beyond my control.

 

Your position (NOT on your back or sitting) plays a big role. I felt most in control while kneeling. My shortest pushing time was 1 min. total and I did not tear. I also had perineal support. You can do the support yourself if nobody else is available/willing.

 

If you don't like the idea of kneeling, side lying is a great choice for preventing tears AND giving moms a better sense of control over pushing.

 

I understand that "couldn't stop" feeling. I've so been there. ;) I used all my willpower to let my perineum win. Also, once the baby's head is almost crowning, I push in between contractions, which lessens the intensity of the "get the baby out" feeling. ETA: What I mean by letting my perineum win is to push as little as possible to appease the pushing relfex and allow the tissues time to open.

 

Avoid "purple pushing" (holding your breath while pushing as someone counts to ten). Instead, breathe the way you would while lifting something heavy.

 

All of these things (side lying/other good position, perineal support, and no purple pushing) can be used for a fast birth. I've done it more than once. :)

Edited May 2, 2011 by Veritaserum

[LizzyBee]

... I was advised to slow down / stop pushing, but trying to stop DS was like trying to stop a freight train--totally beyond my control.

 

My 2nd came out in one push, and the dr told me to stop pushing because the cord was wrapped around her neck. The thought that came to mind was, "It would take a thousand horses pulling the other way to stop this."

[happypamama]

Have them have the warm compresses ready, and they should also be ready to do the perineal support. Definitely state that you want to try side-lying, so that they're ready to help you get into that position. Tell them that you want to listen to your body's cues about pushing.

 

Also, if you can, spend some time in water during the labor. None of mine were waterbirths, but I do think being in the water for a while during labor helped soften the tissues.

[flobee76]

I didn't think to mention that I am petite--about 5 feet tall, 105-110 lbs (I weigh a somewhat more now that I'm pregnant, of course, but that gives you an idea of my frame). Would that have much of an impact on whether or not I'm likely to tear?

 

I haven't read all the responses. I have never had an episiotomy. I am petite just like you (4' 11''). My babies were 7.5lbs, 8 lbs 10poz, and 8 lbs 12 oz. I tore only slightly with the first 2, needing 1 -2 stitches. With the last one, I was able to birth in the position I wanted to (kneeling), and had a teeny tear that didn't require any stitches at all.

 

I think the key is to make sure that the L&D nurses (if you have a hospital birth) give you perineal massages and if you do not have an epidural, most L&D will allow you to be in any position that you feel needed.

[Lovedtodeath]

Are there cases where it's beneficial to have an episiotomy?

I was convinced that I did not want one. Routine episiotomies are not recommended. If however, your baby is in stress after hours of pushing, and or Mom has a very short perineum which could tear all the way to the rectum, it is a good idea for the doctor to do the episiotomy because these things are under the docs control. The decision is not made ahead of time... my doc tried manipulating, stretching, etc.

 

Anyway, tearing is not the reason that I had one. The reason was that I was in labor for a very long time and baby was on oxygen... he needed help to get out sooner rather than later. The decision was made for the baby, not the mom, but I was glad to be done rather than pushing a few more times... I don't know that I could have to tell you the truth.

 

Going in to the doc I was scared to death of an episiotomy and wanted to avoid one at all costs. My doc did one and she made the right decision. I have had no complications from it.

 

I hope that helps.

Edited May 2, 2011 by Lovedtodeath