'Routine' episiotomies aren't necessarily in order


I am always interested in saving women from unnecessary surgical procedures, so I was particularly intrigued by a recent piece of research that questions the need for routine episiotomies during childbirth.

Sixty percent of American women who deliver their babies vaginally have an episiotomy. For first-time mothers, the figure is even higher -- some 80 percent have an episiotomy. To find out why this is, I spoke to Dr. Frank Witter, acting director of maternal-fetal medicine, and to nurse-midwife Lisa Summers, coordinator of nurse midwifery research at Johns Hopkins Hospital.

An episiotomy is a surgical cut made at the opening of the vagina to make passage of the baby easier. Surgical scissors are used to make the cut. Except under emergency circumstances, some form of anesthesia is used.

Prior to the 1920s, episiotomies were rare. Then, two noted obstetricians began advocating the operation in their lectures and writings,calling the birthing process "abnormal" and comparing vaginal birth to a baby having its head caught in a door. The influence of these two men was extraordinary, and within a short time episiotomies were routinely performed throughout the United States. Nowadays episiotomies are usually done for one of three reasons:

* If, when the baby's head is appearing, the obstetrician or midwife believes there might be a tear in the mother's perineum (the part of the body between the inner thighs, with the buttocks to the rear and the vagina at the front), they may perform an episiotomy on the grounds that it is easier to repair than a ragged tear.

* If the baby's shoulders become stuck behind the pubic bone, an episiotomy helps the obstetrician or midwife manipulate the baby's position and speed up delivery.

* Finally, an episiotomy is done to expedite the delivery of babies with medical problems where minutes can make a difference.

The main argument in favor of episiotomies has always been to prevent tearing of the perineum. However, the findings of a recent survey of more than 24,000 women appear to counter this assumption.

The study compared perineal tears in women who had an episiotomy with those who had not had the procedure. They found that first-time mothers who had episiotomies were four times more likely to have bad tears than women who did not have the procedure. For women who had had children before, the rate of tears after an episiotomy was even higher -- almost 13 times greater than the group that had no episiotomy.

fTC One explanation of this is that the natural tearing that occurs without an episiotomy generally involves only a first-degree tear, but if the perineum has already been surgically cut, then it is easier for the perineum to tear further.

To avoid having an episiotomy, find out whether your health-care practitioner routinely performs them. Today, many health providers question the necessity for the widespread use of episiotomy; midwives, for example, perform them in less than 10 percent of their cases.

Be sure to eat a balanced, nutritional diet that leads to healthy flexible tissue in the perineum.

Treat any vaginal infections before giving birth. Vaginal infections can damage tissue and make it more susceptible to tearing at birth.

Exercising the pelvic floor muscles can help to make the birthing process easier. The Kegel exercise (named after the doctor who developed it as an alternative to surgery for urinary incontinence) strengthens the muscles of the pelvic floor and helps women isolate the muscles they need to relax during birthing.

The exercise mimics the process of stopping urine in midstream. Simply squeeze the muscles slowly. Hold for a minute, then relax slowly. Try to do these exercises 20 to 30 times a day.

Perineal massage, which can be taught to the expectant mother and can be self-administered or done by a partner, also can be helpful.

Dr. Genevieve Matanoski is a physician and epidemiologist at the Johns Hopkins School of Hygiene and Public Health. She is a founding director of the school's Institute for Women's Health Research and Policy.

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