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Avoiding an Unnecessary Episiotomy
 national |
consumer issues |
opinion/analysis
 Monday October 31, 2005 12:14 by Tracy Donegan - Doula Ireland tracydonegan at doulaireland dot com Dublin 0870572500
Avoiding the Big E (Episiotomy)
Still a routine procedure in many Irish hospitals learn how you can reduce your chances of getting an episiotomy. Avoiding the Big E (Episiotomy)
Tracy Donegan CD CBHE
Of all the squeamish discussions about birth experiences probably nothing makes you cringe and cross you legs quicker than when talk about labour turns to the big E…..no not the epidural but the episiotomy.
More and more women in Ireland are questioning a once routine procedure that involves enlarging the opening of the birth canal as the baby’s head crowns.
Many Irish hospitals continue this outdated procedure despite significant studies that show routine episiotomies cause more harm than good.
Learn how you can avoid an unnecessary episiotomy.
Imagine the following: if you hold a piece of cloth at two corners and attempt to tear it by pulling at the two ends it’s very difficult to rip. However, if you make a small snip in the center, and pull the corners the cloth rips easily with no resistance.
Episiotomies are ‘said’ to have the following benefits.
• Speed up the birth
• Prevent tearing
• Protects against incontinence
• Protects against pelvic floor relaxation
• Heals easier than tears
The following have been reported as side effects of the episiotomy:
• Infection
• Increased Pain
• Increase in 3rd and 4th degree vaginal lacerations (euphemistically called extensions)
• Longer healing times
• Increased discomfort when intercourse is resumed
Following are some of the myths surrounding episiotomies
Myth: A nice clean cut is better than a jagged tear.
Reality: "Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss, haematoma formation, and infection. . . . There is no evidence . . . that routine episiotomy reduces the risk of severe perineal trauma, improves perineal healing, prevents fetal trauma or reduces the risk of urinary stress incontinence." Sleep, Roberts, and Chalmers 1989
Routine episiotomy (as opposed to episiotomy for an emergency situation such as fetal distress) is a typical example of an obstetrical procedure that still exists despite a total lack of evidence for it and a considerable body of evidence against it.
Myth: Episiotomies help prevent brain damage as the baby’s head ‘pounds’ against the tissues.
Perhaps the most absurd rationale of all is brain damage from the fetal head's "pounding on the perineum." A woman's perineum is soft, elastic tissue, not concrete. No one has ever shown that an episiotomy protects fetal neurologic well-being, not even in the tiniest, most vulnerable preterm infants, let alone a healthy, term newborn (Lobb, Duthie, and Cooke 1986 and 1990.
Myth: Episiotomies help protect the mother’s pelvic floor and reduces her chances of incontinence.
What are pelvic floor problems?
Many women experience pelvic floor dysfunction around the time of birth and/or later in life. Pelvic floor problems include leaking urine (urinary incontinence), leaking gas or — more rarely — feces (bowel incontinence), sexual dissatisfaction, and a sagging of the inner organs (uterine and other pelvic organ prolapse). It is important for every woman to understand what she can do to keep her pelvic floor strong and protect it from injury.
Separating fact from fiction: what causes pelvic floor dysfunction?
These days, there is a lot of conflicting and confusing information about the cause of pelvic floor problems. Vaginal birth has been blamed, and some suggest that enlarging the opening of the vagina by cutting it at the time of birth (episiotomy) or even having a surgical birth when there is no medical complication (elective c-section) will prevent weakened pelvic floor muscles and injury. Unfortunately, there is a lot of false, unproven, and incomplete information on this topic.
Gordon H and Logue M. Perineal muscle function after childbirth. Lancet 1985;2:123-125
Myth: Some women need episiotomies because they are not as ‘stretchy’ as others.
Another absurd example of non researched based practice. There is no medical evidence to support this.
Episiotomies are rarely necessary; you can lessen your chances of having this surgical incision. Some preventative measures that may help are:
• Chose a Doctor who doesn’t do routine episiotomies. (Ask your Doctor how often he finds it necessary to do episiotomies)
• Good nutrition (healthy skin stretches more easily)
• Do your Kegels (exercise for your pelvic floor muscles)
• Prenatal perineal massage
• Slow controlled pushing instead of directed pushing by Doctors and midwives. (Only push when you feel the urge).
• Birth off the bed – not on your back.
Remember, as with any medical procedure, there is always a time and a place where it is a valid option.
Being knowledgeable about your body and any proposed procedures during labour will take you a long way to having a more satisfying birth.
Hartmann K, Viswanathan M, Palmieri R, Gertlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review.JAMA 2005;293:2141-8.
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Comments (5 of 5)
Jump To Comment: 1 2 3 4 5Some preventative measures that may help are:
• Chose a Doctor who doesn’t do routine episiotomies. (Ask your Doctor how often he finds it necessary to do episiotomies)
• Good nutrition (healthy skin stretches more easily)
• Do your Kegels (exercise for your pelvic floor muscles)
• Prenatal perineal massage
• Slow controlled pushing instead of directed pushing by Doctors and midwives. (Only push when you feel the urge).
• Birth off the bed – not on your back.
Proof that the above help, please.
i am a medical student soon to qualify,and have witnessed first hand many surgical procedures.
episiotomies consist of a diagonal incision of very taut tissue beginning at the anal pole of the vaginal opening. traumatic tears track straight posteriorly and tear the vagina and may track to damage the anal sphincter,in this regard intervention succeeds in reducing the worst case to a shorter safer scar.
epidurals reduce response to contractions,negate the natural help of gravity in the squatting position which is normal in mammals,and i dislike the idea intensely.babies are born sluggish and respond less quickly to the first breath.
diet does indeed help skin elasticity,and hence the ease of birth.
regarding exercise : prenatal strenghtening of pelvic muscle is well advised ,as many years later it stops prolapse of the uterus through the vagina.And generally it is a healthy exercise in males and females,it is a prescribed practice in advanced yoga.
i am glad this topic was raised and the article seems well researched and accurate.
Chose a Doctor who doesn’t do routine episiotomies. (Ask your Doctor how often he finds it necessary to do episiotomies) - this is common sense. The 'proof' is in the answer your consultant gives you - either they do these routinely or not....
• Good nutrition (healthy skin stretches more easily) - I don't believe there has been any research on this item but it's reasonable to assume that women who are healthy and have good nutrition would have healthier skin....
• Do your Kegels (exercise for your pelvic floor muscles) - prevents pelvic floor damage and speeds recovery
• Prenatal perineal massage - has been shown in several studies to be beneficial
• Slow controlled pushing instead of directed pushing by Doctors and midwives. (Only push when you feel the urge). Recent research has shown that directed pushing shortens labour by about 15 minutes but increases the likelihood of perineal damange. Think of it logically - when the skin has time to stretch and expand it's less likely to tear but when a mother is instructed to push her baby through tissues that are not ready then injury is more likely.
• Birth off the bed – not on your back - this makes pushing harder (you are pushing uphill) It also restricts blood flow to your baby.
Panel Recommends Curb in Episiotomy
Experts Say Procedure Contributes to Incontinence in Women
By Todd Zwillich
WebMD Medical News
Reviewed by Louise Chang, MD
Dec. 12, 2007 -- A routine procedure performed on up to 1 million American women per year may be needlessly contributing to incontinence in those women, an expert panel concluded Wednesday.
The procedure, known as episiotomy, involves cutting tissue between the lower vagina and the anus when women are in childbirth. While it is often used to aide delivery in cases of fetal distress or complicated childbirth, its use in routine births should be curtailed, the experts say.
"The routine use of this procedure should be seriously reconsidered," says C. Seth Landefeld, who led an expert consensus panel on fecal and urinary incontinence sponsored by the National Institutes of Health.
The procedure runs the risk of damaging the anal muscles, which in turn may cause up to 1,000 cases of fecal incontinence per year, says Katherine Hartman, MD, PhD, a professor of obstetrics and gynecology at the University of North Carolina, Chapel Hill.
"It has a proven risk of damage," Hartman says. "The connection is a pretty direct link."
Incontinence is the catch-all term for the involuntary loss of urine or stool. The risk of fecal and urinary incontinence increase with age; they are more common in women than men.
But both sexes are affected: It is estimated 5% of adults 65 to 74 and 20% of those over 85 experience fecal incontinence. One in five women and one in 20 men are estimated to suffer urinary incontinence by the time they're 45, according to the report.
(What are some of your most embarrassing incontinence moments? Share anonymously on WebMD's Women’s Health: Friends Talking board.)
Incontinence Is Undertreated
While the problem is widespread, it is vastly undertreated, the panel warns.
"The shame, embarrassment, and stigma associated with these conditions pose significant barriers to seeking professional treatment, resulting in many persons who suffer from these conditions [going] without help," the report states.
In addition, most health plans don't pay doctors to do an independent evaluation for incontinence or counsel on weight loss, exercise, or specialized pelvic floor exercises that may help prevent it, says Landefeld, who directs the Center on Aging at the University of California, San Francisco.
And while articles in women's magazines often include suggestions for women to perform Kegel exercises to strengthen the pelvic floor muscles, experts say those exercises are frequently done incorrectly.
They urge more formal training for women to teach them how to isolate the pelvic floor muscles in a way that can be effective against urinary incontinence.
"Many women and men and many practitioners don't have a good idea of what the pelvic floor is," says Eileen Hoffman, MD, an associate professor of medicine at New York University. "You have muscles down there that if you don't have tone in [them], you're much more likely to have incontinence."
A high proportion of incontinence cases occur in nursing homes, according to the report. But instead of physical problems, many cases occur simply because elderly residents don't get to the bathroom in time.
The panel urged new policies that increase staffing at nursing homes so that residents don't sit, sometimes for hours, needing to use the toilet.
"That is probably more expensive then just letting them sit there in diapers," Landefeld says.
having had the surgery- and that is what it becomes when you have an episitomy can I just say this:
What are diapers?
and stigmatising the issue by focussing on the biological is not helping survivors, now if you
want to contextualise the issue politically-that would be interesting , otherwise, suggest
a problem page or website link-cos I am sick of reading negatives.
Not all episitomies are like the study above- but generally, yes they cause damage, limitation
and depressions.