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Tears versus Episiotomies

What's worse? An episiotomy or a tear? Tough choice, huh? The answer—none of your business. OK, not really. It is, of course, your very personal business but not your decision to make at delivery, most of the time. One of the most popular items on a birth plan is the ever-popular demand—no episiotomy under any circumstances. Really? There's no situation where an episiotomy would be OK? How about if you've been pushing for 4 hours and the only thing separating your baby from your perineum (the skin, tissue and muscle between your vagina and rectum) is a small episiotomy? What if your baby is crowning and suddenly, his heart rate drops down to 50 (normal being above 110 and below 160) and stays there. What if your doctor needs to use forceps or a vacuum extractor because the baby's in trouble. She wants to get her out NOW. There's no time for a c-section but there's not enough room down there for her instruments? How about if you're at risk to tear three different ways til Tuesday and your midwife knows it will be tough to put you back the way you were originally made? Then could they do an episiotomy?

Now that I've scared you, let's talk. Most doctors and midwives avoid episiotomies at all costs. Yeah, back in the day, they were standard issue, along with a shave and an enema. Not anymore. Nowadays, the goal is an intact perineum every single time. If that's not to be, and a tear is in your future, it's usually not a big deal. Most tears are easy to repair and heal really well. All midwives and doctors prefer an intact perineum and will go to great lengths to save your butt. Standard issue these days are mineral oil stocked with delivery supplies for perineal massage during pushing and hot compresses to relax the tissues so they'll stretch and stretch and stretch. And most of the time they will. But sometimes, they won't. This is the part that's not really your decision to make.

Let's set the stage—your knees are pulled up to your shoulders. You're pushing with all you've got. You're exhausted, sweaty and a room full of people are yelling at you to Push, Push, Push. Your partner has counted to ten through dozens of contractions and guided you through countless cleansing breaths and though nowhere near as tired as you, is carrying his own load of fatigue, excitement and worry. Your nurse is at your side with warm baby blankets ready and your midwife is at your feet (OK, not really your feet) gloved, gowned and ready to catch the latest edition to your family. Your baby's head is crowning and everyone's complimented the full head of hair emerging from your nether regions. Your midwife says, "OK, take a deep breath and PUUUSH!" And you do again, and again and again. Your vagina is stinging like crazy and you're sure it can't stretch any further. All of a sudden, you're thinking about Johnny Cash and wondering how the heck he knew about the "burning ring of fire" when, clearly, he'd never pushed a baby out. And then your midwife says, "What would you prefer? A tear or an episiotomy?" Again I say, tough choice. And not a decision you're in any way able to make at that moment. You can't see what's going on down there. You're occupied on the other end of the bed. And that's why you hired a professional. To make that decision for you.

Once again, most of the time, it's a tear or nothing. Hardly anyone does episiotomies routinely anymore. Studies show that an episiotomy can result in more damage to the rectal sphincter (the muscle that surrounds the rectum) than a tear so there's good reason to be concerned about it. That's why most doctors don't do them routinely. Sure, some of the old-school doctors will because it's part of their standard bag-of-tricks but they're no longer the gold standard of care. The time to ask the episiotomy question is at the beginning of your prenatal care. If your doctor says, "you bet, I do episiotomies every time" then you decide if he/she is the doctor for you. But if you're already singing Johnny Cash—that's no time to ask. And very, very few mothers give a hoot at that particular moment anyway. Just get the baby out for God' sake.

So, what if you tear or get an episiotomy. How bad is that and will you ever be normal again? Both are graded 1st through 4th degree. First degree is skin only. Second degree involves the underlying pereneal/vaginal tissue. Both are pretty easy to stitch up and you'll be good as new within a month or so. Third degree involves the rectal sphincter and 4th degree—the rectal mucosal tissue. Third and fourth degree tears/episiotomies are bad news and require a lot of skill and needlework to repair. If you're delivering with a midwife or family practice physician, they're very likely to call in an obstetrician to do that repair for them. But they can be repaired and heal very, very well. Yes, you'll be able to poop and have sex just like before kids. Still, nobody wants a third or fourth degree laceration. That's part of the reason forceps are less popular these days and c-sections are more popular. Some studies say long-term effects of a really bad tear/episiotomy can result in incontinence down the road. There are an equal number of studies that say, Nuh unh, not true —incontinence is caused by aging not damage. There's actually a study of a bunch of virgin nuns who had the same rates of incontinence in their upper years as women who'd had children. Whatever. Nobody wants a third or fourth degree repair if they can help it.

Trust is essential here. Your doctor/midwife has your best interests at heart. It's their job to save your booty. Talk to them early in your prenatal care and ask about their episiotomy policy, what measures they take to avoid them and under what circumstances they've found themselves doing them. And, OK, go ahead and remind them on your birth plan but really, ladies, by the time you're singing Johnny Cash—you're not going to care. Just get that baby out for God's sake.

Got a question for Jeanne? E-mail it to labornurse@fitpregnancy.com and it may be answered in a future blog post.

This Fit Pregnancy blog is intended for educational purposes only. It is not intended to replace medical advice from your physician. Before initiating any exercise program, diet or treatment provided by Fit Pregnancy, you should seek medical advice from your primary caregiver.

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