By: Diana Barnes-Brown for Uterus1
Episiotomy, or the partial cutting of the tissue between the vagina and the anus during labor, is a practice that has been used for many years by obstetricians.
In the past, many argued that the procedure could prevent tearing, reduce pain and lower the chance of infection due to contamination of the vagina with fecal matter in the case of severe tearing. Others argued that episiotomy would reduce the risk of urinary and bowel incontinence, increase sexual enjoyment, and prevent muscle weakening in the vagina.
But despite the fact that episiotomy has been the party line in obstetric care for a long time, there are many physicians, midwives, and mothers who decry it as dangerous and unnecessary.
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Those interested in trying the technique should note that perineal massage should be done only after consultation with a qualified caregiver, because incorrect practice can lead to tissue damage and bruising.
Recently new evidence from a variety of sources has helped to debunk pro-episiotomy arguments as being primarily myth-based, adding fuel to the fire of skeptics, who argue that the procedure is an archaic tradition, largely unnecessary for ensuring a safe birth.
One new study indicates that whether or not women have an episiotomy has a lot more to do with how long their physician has been practicing than any objective rating of their risk of suffering dangerous or destructive tearing.
According to researchers at the Maimonides Medical Center, who reviewed the data surrounding 2,000 births, obstetricians who had been practicing for 25 years or more were three times as likely to perform an episiotomy than those who had been in practice for fewer than six years.
Further research conducted by doctors at the University of Pittsburgh examined roughly 27,000 deliveries and found that women who went to private-practice physicians were seven times more likely to have an episiotomy than those who went to OB/GYN residents or hospital caregivers.
The authors of the study suspect that in the environment of mentoring and education in hospitals, which are also teaching organizations for young physicians, allows all doctors on staff access to updated information on the latest breakthroughs in patient care, and keeps older or longer practicing physicians’ techniques from becoming stale or outdated, while those in private practice are exposed to new research and information only through their own initiative, often with little institutional pressure or support. With the added pressure of additional time devoted to insurance and coverage issues and the need to pack as many patients into every day as possible, in relief of interacting with newer doctors and a comprehensive teaching staff, many private practice physicians may lack the time and resources to stay up-to-date.
Finally, a review of 45 studies on episiotomy conducted by researchers at the Agency for Healthcare Research and Quality and published in a recent issue of the Journal of the American Medical Association has shown that episiotomies are routinely associated with longer healing time, higher risk of injury and increased pain.
Despite the fact that the American College of Obstetrics and Gynecology has said that episiotomies should not be routine practice since 1983, the study found that in 1999 and 2000, roughly one in three natural childbirths in America – 33 and 35 percent per year, respectively, or about 1 million women annually – received episiotomies.
Independent estimates of episiotomy rates yield numbers of about 600,000, but Dr. Katherine Hartmann, the study's lead author and a researcher at the University of North Carolina, noted that many hospitals do not have accurate records of episiotomy rates. She said that these rates are dropping, but not nearly fast enough.
“Our systematic review finds no health benefits from episiotomy. We found fair to good evidence… that the immediate outcomes for routine (liberal-use policies) episiotomy are no better than those for indicated use of episiotomy under more restrictive-use policies,” wrote the authors.
“Indeed, routine use is harmful to the degree that it creates a surgical incision of greater extent than many women might have experienced had episiotomy not been performed.” They added that while some tearing might occur during childbirth, it is usually limited and can be repaired with a simple stitch or two.
So, while some births may truly require episiotomy, current information from many sources suggests that most do not. Those hesitant to undergo the procedure should discuss prospective OB/GYNs’ practices frankly well before heading to the delivery room. Physicians with episiotomy rates of 10 percent and under have better post-delivery outcomes than others, note researchers at the University of Pittsburgh.
For those who wish to investigate alternate means for a safer, more comfortable birth, the practice of daily perineal massage – massaging the tissue between the vagina and anus – for several weeks before the baby is due may lead to more elasticity and less chance of serious tears, which are one of the main motivations for performing legitimate episiotomies. Perineal massage may also decrease pain during delivery.
According to the team of doctors, nurses and midwives at Childbirth.org, a non-profit organization that offers counseling on childbirth and infant care, “like training muscles to perform at their best in an athletic event, conditioning the tissues around the vaginal opening with massage prepares the perineum to perform.”
They add that those who practice perineal massage daily for the final six weeks of pregnancy experience less pain and stinging during crowning (the stage of labor when the baby’s head begins to emerge from the vagina). Also, perineal massage “familiarizes a woman with stretching sensations in this area so she will more easily relax these stretching muscles when stinging occurs just before the moment of birth.”
As with all health concerns, the path to better care is better communication. Women should consult with doctors, midwives or other caregivers who will be assisting with labor and delivery to make sure everyone is on the same page before going ahead with any procedure or course of treatment. Quality caregivers will listen to their patients’ concerns, and help them come to a good decision about the best decision for mother and baby.