During labor, doctors routinely cut a 1-3 inch incision in a woman’s perineum– the skin and muscle between the vagina and the anus– to increase the size of her vaginal opening. After the birth, he’d stitch it up tightly in the hopes of improving a couple’s future sex life (or the husband’s, at least). But too often the procedure did the opposite, occasionally making mom feel so sore and uncomfortable she simply could not have sex, let alone good or frequent sex.
The official name for this procedure is an “episiotomy.” Routine episiotomies are no longer recommended, but many argue they are still performed too often. And women are getting pissed off about it.
Recently The Huffington Post ran a story about several women who felt their episiotomies were unnecessary, painful and harmful. One of the women was Babble blogger Rebecca Woolf, who has been a vocal opponent of routine snipping:
“My episiotomy was not slight. It was severe and not only did it take me weeks before I could pee without crying, but it took me a year before I stopped itching my crotch. It was like a yeast-infection on speed as it was healing. Not fun at all. Not only that, but it STILL doesn’t feel the same down there. He cut through the muscle tissue so the whole vag-area feels just very funky and sad.”
For several generations doctors thought a “clean cut” would be better than a “messy tear.” The cut was supposed to help women heal more easily, experience less urinary incontinence and enjoy a better sex life. In 2005 a large study found that episiotomies not only didn’t improve recovery times or pain after birth but increased the risk of deeper tears and pelvic floor problems. While most first time moms do tear during childbirth, most tears are superficial, 1st or 2nd degree tears, affecting only the surface of the body. Occasionally women tear into the muscle but an episiotomy always cuts through the muscle and they can lead to deeper 3rd or 4th degree tears, kind of like when you snip the edge of a piece of cloth can make it rips more easily. In 2006 ACOG changed their guidelines, discouraging episiotomies unless medically necessary.
“Medically necessary” typically means that the baby needs to come out right now and we don’t have time to wait for the perineum to stretch slowly and an episiotomy has fewer risks than pushing the baby back up and doing a c-section. (Sometimes an episiotomy is necessary and clearly reduces risks for mom and baby.)
But as this plays out, “medical necessity” ends up being a pretty subjective call on the part of the care-provider.
A 2005 landmark study on home-births published in the British Medical Journal tracked over 5,000 mothers in the US and Canada, and found the episiotomy rate for low risk mothers was 2.1% at home, vs 33% in hospitals. These are all low risk moms but very different rates of episiotomy, suggesting care-provider preference and context play a key role in determining whether you’ll get one.
You can see this today. In NYC, the current rates vary tremendously: At St. Luke’s Roosevelt Hospital where there’s a 64% epidural rate, 8.7% of women are given an episiotomy, that’s half the state average. Across town at Cornell, the episiotomy rate is 35% (double the state average), with a 97% epidural usage.
All of this suggests that the best way to avoid an episiotomy is to get a doctor who rarely performs them.
You can also get a doctor or midwife who has lower rates of other interventions that can increase the need for an episiotomy such as epidural, vacuum or forceps delivery, doctor-directed pushing (as opposed to mom-directed pushing) and pushing on your back. Childbirth Connection provides a comprehensive list of tips for avoiding an episiotomy.
If you want an epidural, as many laboring women do, you can reduce the risks of episiotomy by asking that medication be turned down for pushing so you can get in a more upright position and feel things a bit more to give you increased control. You can also hire a doula, as studies show fewer interventions are used when a doula is present.
But really the number one way to avoid an unnecessary episiotomy is to go with a doctor who doesn’t do them. Rebecca Woolf did this for her second birth and says she was up and taking long walks within a couple of days.
“I had a shitty experience that led to a really incredible one,” Woolf said. “For me, it’s just important to share [my story] with other people, so that other women will put up a little more of a fight than I did.”
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