Episiotomy

Avoiding a Tear After a Prior Episiotomy

Posted on August 19, 2009. Filed under: Episiotomy, Vaginal Tear | Tags: , , , , |

This is an email response to the question:

If I had an episiotomy during my first delivery, will it increase the risk of tearing next time? Does perineal massage help?

First, here is some statistical information on tears…

How common are tears/episiotomies?

Most women who have a vaginal birth have either a tear or a cut. A few women have both.

We don’t know exactly how many women have a tear in the perineum during childbirth. Doctors and midwives don’t always record small tears. Experts think that at least a third of women in the United States have a tear large enough to need stitches.

In one study from the United Kingdom, more than 8 in 10 women had a tear or cut during a vaginal birth.

And about 7 in 10 needed stitches.

Bad tears, which go all the way from the vagina to the anal opening (third-degree or fourth-degree tears), happen less often. But we don’t know exactly how many women in the United States have a bad tear. In one study from Canada, about 7 in 100 women who give birth had a bad tear.

Your chance of having a cut (episiotomy) depends on where you live. In the United States, about a quarter of women have a cut. In some eastern European countries, nearly all women have a cut during delivery.

Sources for the information on this page:

  1. Graves EJ, Kozak LJ.National hospital discharge survey: annual summary, 1996.Vital Health Statistics. 1999; 13: i-iv, 1-46.
  2. Audit Commission.First class delivery: improving maternity services in England and Wales.London: Audit Commission Publications, 1997.
  3. McCandlish R, Bowler U, van Asten H, et al.A randomised controlled trial of care of the perineum during second stage of normal labour.British Journal of Obstetrics and Gynaecology. 1998; 105: 1262-1272.
  4. Sultan AH, Kamm MA, Hudson CN.Anal sphincter disruption during vaginal delivery.New England Journal of Medicine. 1993; 329: 1905-1911.
  5. Wagner M.Pursuing the birth machine: the search for appropriate technology.In: Wagner M. Pursuing the birth machine: the search for appropriate technology. Ace Graphics, Camperdown, Australia; 1994.
  6. DeFrances CJ, Hall MJ, Podgornik MN2003 National Hospital Discharge Survey. Advance Data from Vital and Health statistics No 359Advance Data from Vital and Health Statistics 2005.
This information was last updated on Nov 07, 2008

I have had this question a few times because most of my doula clients are second timers. While I have not found any hard studies on this topic (I am sure there have been some but I can’t find any), it has been suggested that up to 50% of women with an episiotomy scar will have a 2nd degree tear in subsequent births. That’s a big number but there is a lot of explanation that needs to go with that.

It is also important to understand that a vaginal tear is generally better than having an episiotomy. Tears typically do not tear as deep and far as a cut will and episiotomies actually increase the risk for a third or fourth degree tear. This is because once the cut is done the head emerging can cause the cut to tear farther back and deeper into the muscle. Tears will usually heal faster too.  (this was not in the original email).

The scar tissue is a weakened area so it is more likely to give way but there is no guarantee that it will tear in a subsequent delivery. It’s not that the scar prevents vaginal stretching, it’s that the scar itself is weak and not as pliable as vaginal tissue. I had a client who had a huge episiotomy her first birth, it require 50 stitches and took months to heal. She had a surface tear her second birth and only needed 3 stitches. Many docs and mw’s wouldn’t have even stitched what she had. She said that within three days she felt completely normal and fine.

Also, 2nd degree tears are really not that bad. They will usually heal on their own without stitches but most OBs and hospital MW will stitch them. Homebirthers tend to opt out of 2nd degree stitching (because it is invasive and interferes with bonding) and they do fine. A 2nd degree tear doesn’t tear into the perineal muscle, it’s more is a skin tear. Of my 3 clients that had 2nd degree tears, two felt fine in less than a week and one was fine after less than two weeks. My point to all of that is that you would much rather tear a 2nd degree tear than to have an episiotomy so don’t let that scare you. Another thing worth mentioning is that none of them felt the tear as it happened and none of them had any kind of drugs during labor.

When you crown unmedicated, you feel the ring of fire for a few minutes, then the area goes numb because the nerves have so much pressure from the baby’s head. It’s natures own anesthetic and it’s also natures way of helping you not to tear. When a woman is left to push as her body tells her (rather than a nurse or doc coaching her) then she will instinctively not bear down when crowning because it burns. This allows the vaginal tissue to stretch as opposed to being push on as hard as possible and forcing the baby’s head out to quickly. This is why it is so very important to instinctively push rather than have cheering leading and counting pushing. Of course, it’s pretty much necessary when you have an epidural because you can’t really feel what your body is doing but when you are unmedicated you know exactly what’s happening. It’s also hard to get staff to let mom push instinctively. Most are so used to coaching epiduralized moms that they do not even realize that an unmedicated mom in an upright position needs absolutely no help.

This is also why it’s so important not to push on your back in the bed because then you aren’t giving the staff free access to everything. In addition to keeping people off your vagina, horizontal pushing also helps you stretch better because of gravity (increased blood flow to the area helps stretching plus it brings baby down with less effort). A squat position (like using a squat bar on the bed) also helps you to stretch better just by way of positioning. It just opens everything up. This is REALLY hard to achieve in a hospital birth most of the time. You will have to be firm and aggressive to make it happen and you will also have to be strong enough to initiate it during labor. Really you should hire a doula but you knew I would say that before you even emailed me;)

That said, there are a few women who require an episiotomy and I say require very lightly, I don’t really think there is any reason to give one other than a SERIOUS decel in the fetal heart tones that requires immediate delivery but that is very rare. It unfortunately is way over used as a reason. There is a difference in a decel and a very serious decel . When this happens to an unmedicated mom, a pressure episiotomy is done but can only be done that way after the ring of fire is no longer felt, meaning the nerves are numb and mom won’t feel pain from the cut. It sounds horrifying and it is but like I said, there is no cutting pain. If the nerves are not numb then a local anesthetic can be given if there is time. Again, these are very rare circumstances and there are ways to prevent this from happening.

The debate is out on perineal massage. Some people swear by it others say it doesn’t work. Don’t allow anyone to do it during pushing though, as it does increase the risk of tearing. If you think about it, it makes sense, someone else is touching you and they cannot feel what they are doing, only you can. You would touch more gently or firmly because you know what is happening. The best thing anyone else can do is to use warm compresses and perineal support which is still easily done if mom is upright. I recommend that moms support their own perineum because again, you are the one that is feeling what is happening and know how much or little pressure you need.

As for perineal massage during pregnancy, even if there is no solid evidence that it works, it can’t hurt and if nothing else it teaches you to relax your bottom. If your partner can do it for you it will teach you how to let the muscles go. For instance, he would use a finger on each side at the bottom of your vagina (while you are sitting up against the headboard or wall, oh and use lube). Then he would gently sweep the fingers out in opposite directions and kind of down and while he is doing that you just completely relax and concentrate on letting the muscles loose. Here is a link

http://www.bestdoulas.com/perineal.pdf

But if your partner were doing it he would use his index fingers instead of thumbs.

I definitely would not use the same care provider that did your episiotomy the first time even if you like them. The thing is that even if you tell them you do not want it under any circumstance and that you would rather tear, those that use it, almost always use it and if they say “we only do it if it’s necessary” then you can count on having one. If you truly want to avoid another one and you truly want to reduce the risk of tearing, then you will need a provider that is more hands off and who will encourage you to get off your back and who is pro-natural birth. Most of them will SAY they are though so that’s the tricky part. This again is where I say hire a doula because doulas usually know the scoop on the different providers in the area. They see these docs and mws in action and know how they really are.

I am not trying to freak you out or be anti doc or negative it’s just that I have seen it happen. I have seen docs tell clients they are pro VBAC and want them to have the birth they want then threaten them with statistics that are not true or try to force a repeat c section on them. I have seen them tell clients that they support upright non coached pushing but in labor force them on their backs and start counting to 10. I think a lot of times they just tell mom what ever she wants to hear to get her to be quiet then when it comes down to the birth, they do whatever they want. Yes they do know best when there is a real emergency and either mom or baby is in trouble. hand down. But when it comes to unmedicated birth and leaving the body to do what it is supposed to do, they are not because the majority of American women get epidurals and that changes things. I would suggest finding that provider who supports your wishes and believes in your body so that you do not have to fight for what you are entitled to. If you are set on keeping the provider (if it’s the same one) then definitely hire a doula so you don’t have to fight alone. (sorry for the little speech:)

SO in short, you do have a risks but you have lots of options and you can set yourself up for the least risk of tearing.
EDIT: I am adding THIS LINK for more information on the history of episiotomies and their use today. This is a great read. Here is the intro…

The following piece was submitted by Rita Ledbetter, CNM ~ she is my midwife and works in the Medical Arts office in Moline.  I asked her if she’d be willing to share her knowledge on the subject of episiotomy ~ to cut or not to cut when delivering.  I am very appreciative that she took the time to write and submit this article so that expectant mothers can be more informed when developing their birth plans!

Hi -this is Abby’s midwife Rita.  She asked me to write a little about episiotomy – the cut made at the opening of the vagina (perineum) when a baby is being born.  Routine episiotomy is no longer recommended but still occasionally is needed.

History:
Birthing babies is not new and tearing or lacerations of the opening of the vagina have always been part of the process of birth.  Some women had tears, some did not.  In olden times it was common to allow as many cobwebs as possible to grow in the home as a woman prepared for childbirth.  If a tear happened during childbirth the sticky cobwebs were packed into the tear and the woman was kept in bed for 10 days or so with her legs closed to allow her bottom to heal…..Go HERE to read more

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