An episiotomy is one of the most common medical interventions during childbirth, and it’s also one that concerns most mothers-to-be. Here’s what you need to know, writes midwife Hulda Thorey.
Historically, an episiotomy, which is an incision made between the anus and vagina, was thought to be the lesser of two evils. While it does cause discomfort and scarring, can cause infection, and is certainly an impediment to an early return to sex, the greater evil was thought to be a very damaging and uncontrolled tear that might otherwise damage the major anal muscles. For this reason, an episiotomy was carried out routinely, especially for first-time mums.
But then people – quite rightly, in my opinion – started asking questions, and in 2000 and 2005 two major studies indicated that, in fact, in an uncomplicated delivery the chance of a major tear was quite small and certainly didn’t justify a routine episiotomy and all the negatives that come with it.
As a result, The World Health Organization, the Royal College of Obstetricians and Gynaecologists and The American College of Obstetricians and Gynecologists now all recommend a “restrictive” approach to an episiotomy. Under a restrictive approach, doctors will typically only recommend an episiotomy when: there is foetal distress and there is no time to wait; forceps or a vacuum are needed to assist in the delivery; the mother doesn’t feel a sufficient urge to push (for example, with an epidural); the perineum is very tight (possibly because of an earlier scar); or there are early signs of tearing.
In Hong Kong, the restrictive approach met with resistance because it was thought that Chinese women had a shorter perineal length, and were therefore more likely to suffer a major tear. However, a 2009 study by doctors at the Prince of Wales Hospital showed that, in fact, perineal length was not related to the risk of a perineal tear. The study also showed that when a restrictive approach was taken, the episiotomy rate was reduced from 73 to 27 per cent, and among those who didn’t have an episiotomy, no one suffered a major tear.
There are steps you can take to reduce your chance of an episiotomy – assuming your doctor or midwife is willing to take the restrictive approach.
- Discuss your pain relief method with your doctor or midwife. A full epidural will increase the need for an episiotomy: because you cannot control or feel the urge to push, it is more likely the doctor will need to use forceps or a vacuum, which usually do require an episiotomy. However, epidurals can sometimes be managed so the effect wears off by the time you need to push.
- Work with your midwife or doctor to control the birth, pushing and waiting at the right times. If you don’t feel the urge to push, it’s often because your body is saying, “Stop, give me time to stretch.” You should also be using this rest time to regain your energy for when you do need to push, reducing the need for medical assistance.
- Find positions where you have more control when pushing and can clearly feel the urges. There are also positions that help reduce the urge, and your midwife might suggest such positions if she feels your cervix, or later the perineum, is not quite ready to take the strain.
- Touching the perineum with your own hand when the head is crowning helps you get a better feeling of the actual progress of the head coming down. Sometimes the counter-pressure will help you feel more confident in the process and your ability to push, which can reduce both your need for an episiotomy and the risk of severe tearing.
- Perineal massage can help, especially if there is previous scarring. It can also help increase your confidence as you get to know your own body better. Ask you prenatal experts for guidance.
- Most importantly, try to be calm and patient during your delivery and let nature help you through.
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