The use of episiotomy, once a standard practice for all first time mothers and most
others, has become controversial in recent years. Expectant and new mothers began to complain and created a demand for midwives
and physicians who used techniques to protect the perineum and avoid episiotomy, except when the fetus is in distress or when
the perineum is unable to stretch. These practitioners have an episiotomy rate of 8 to 20 percent.
Recent scientific studies comparing routine episiotomy (meaning an episiotomy rate of
50 to 90%) to a selective policy on episiotomy (a rate of approximately 10%) have found little benefit to a policy of routine
episiotomy and some real risks. Many of the long-held beliefs about the advantages of episiotomy simply could not be
confirmed.
As a result of the accumulated evidence against routine episiotomy, many caregivers
are learning delivery techniques that protect the perineum. Others are still not convinced that avoiding an episiotomy is
a good idea. Pregnant women should discuss this matter with their caregivers.
It is better for the woman not to ask her caregiver if he or she does routine
episiotomies. It is better to ask the caregiver's opinion on episiotomy versus no episiotomy, and how often they believe women
need one. Most caregivers say they restrict episiotomies only to those cases where it appears that the mother will tear or
that the baby is in distress. The differences between caregivers lie in how often they believe that the mother will tear
and in how negatively they perceive tears. [italics mine] Those caregivers with a high episiotomy rate say that most
first time mothers will tear without an episiotomy and that a tear is always worse than an episiotomy. They believe that some
second time (or more) mothers can deliver without tearing. Those with low rates say that the chances of tearing at all are
approximately 50/50, and that serious tears or even tears that equal an average episiotomy in degree are very rare. They also
may describe techniques they have for protecting the perineum.
Therefore, the woman needs to decide if she would rather risk a tear than have an episiotomy
and tell her caregiver. The more experienced a caregiver is in avoiding episiotomies, the better are her chances of an intact
perineum or a minor tear.
Following are things that the woman and her caregiver can do to help safely avoid an episiotomy:
Prenatally:
- Pelvic floor contraction exercise (Kegel and Super Kegel)
- Pelvic floor relaxation and "bulging" exercise
- Practice various positions for second stage: semi-sitting, side-lying, all fours, standing/leaning,
squatting, etc.
- Perineal massage
- Education - what to expect during second stage
- Good nutrition to promote healthy tissues
During Second Stage:
- Reassurance and encouragement that intense sensations are normal
- Relaxation of the perineum
- Spontaneous bearing down (DON'T RUSH)
- Positions of comfort or to promote slow progress: gravity-neutral positions to promote progress (Semi-sitting,
squatting, standing, supported squat)
- Use of mirror, touch of the baby's head to encourage efficient bearing down efforts
- Perineal massage and support
- Hot compresses
- Cessation of bearing down when stretching and burning are felt; pant or blow instead
- Frequent monitoring of fetal heart rate
